Provider Demographics
NPI:1376824466
Name:COOK, NILES (MS)
Entity Type:Individual
Prefix:
First Name:NILES
Middle Name:
Last Name:COOK
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16535 SW TV HWY
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-5143
Mailing Address - Country:US
Mailing Address - Phone:503-259-3106
Mailing Address - Fax:503-649-7405
Practice Address - Street 1:16535 SW TV HWY
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-5143
Practice Address - Country:US
Practice Address - Phone:503-259-3106
Practice Address - Fax:503-649-7405
Is Sole Proprietor?:No
Enumeration Date:2011-09-01
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR210855Medicaid